RESUMO
INTRODUCTION: Methadone and buprenorphine/naloxone (BUP/NX) titration parameters (eg, range, duration, and rate) can vary during opioid use disorder (OUD) treatment. We describe methadone and BUP/NX titration patterns and their associations with treatment outcomes among individuals with a prescription-type OUD. METHODS: We used data from a 24-week open-label, multicenter randomized controlled trial, including N = 167 participants aged 18-64 years old with prescription-type OUD who received at least a first dose of treatment. Descriptive analyses of methadone and BUP/NX titration patterns were conducted, that is, range and duration from first to maximum dose, and rate (range/duration ratio). Outcomes included percentage of opioid-positive urine drug screens (UDS) and treatment retention. Adjusted linear and logistic regressions were used to study associations between titration patterns and percentage of opioid-positive UDS and treatment retention. RESULTS: Methadone doses were increased by a mean dose range of 42.4 mg over a mean duration of 42.2 days. BUP/NX doses were increased by a mean dose range of 8.4 mg over a mean duration of 28.7 days. Only methadone dose titration range (odds ratio: 1.03; 95% CI, 1.01 to 1.05) and duration (odds ratio: 1.03; 95% CI, 1.01 to 1.05) were associated with higher retention. Only methadone dose titration rate was associated with lower percentage of opioid-positive UDS at weeks 12-24 ( B : -2.77; 95% CI, -4.72 to -0.81). CONCLUSIONS: Specific parameters of methadone titration were associated with treatment outcomes and may help in personalizing treatment schedules. Sustained methadone dose titration, when indicated, may help increase retention, whereas faster dose titration for methadone may help decrease opioid use.
Assuntos
Buprenorfina, Transtornos Relacionados ao Uso de Opioides, Humanos, Adolescente, Adulto Jovem, Adulto, Pessoa de Meia-Idade, Buprenorfina/uso terapêutico, Naloxona/uso terapêutico, Analgésicos Opioides/uso terapêutico, Metadona/uso terapêutico, Antagonistas de Entorpecentes/uso terapêutico, Tratamento de Substituição de Opiáceos, Combinação Buprenorfina e Naloxona/uso terapêutico, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, PrescriçõesRESUMO
Methadone and buprenorphine/naloxone are opioid agonist therapies for opioid use disorder treatment. Genetic factors contribute to individual differences in opioid response; however, little is known regarding genetic associations with clinical outcomes in people receiving opioid agonist therapies. Participants diagnosed with opioid use disorder, principally consisting of prescription opioids (licit or illicit), were randomized to methadone or buprenorphine/naloxone for 24 weeks of daily treatment (NCT03033732). Urine was collected at 12 biweekly study visits and analyzed for non-treatment opioids. Variants in genes involved in methadone metabolism (CYP2B6, CYP2C19, and CYP3A4), buprenorphine metabolism (CYP3A4 and UGT2B7), and µ-opioid receptor function (OPRM1) were genotyped and analyzed for their association with the number of non-treatment opioid-free urine screens. Primary analyses focused on the last 12 weeks (6 study visits, post-titration) of treatment among those reporting White ethnicity. Additional sensitivity and exploratory analyses were performed. Among methadone-treated participants (n = 52), the OPRM1 rs1799971 AA genotype (vs. G-genotypes, i.e., having one or two G alleles) was associated with greater opioid-free urine screens (incidence rate ratio = 5.24, 95% confidence interval (CI) = 2.43-11.26, P = 0.000023); longitudinal analyses showed a significant genotype-by-time interaction over the full 24 weeks (12 study visits, ß = -0.28, 95% CI = -0.45 to -0.11, P = 0.0015). Exploratory analyses suggest an OPRM1 rs1799971 genotype effect on retention. No evidence of association was found between other genetic variants, including in metabolic variants, and non-treatment opioid-free urine screens in the methadone or buprenorphine/naloxone arms. Those with the OPRM1 rs1799971 G-genotypes may have a poorer response to methadone maintenance treatment, an effect that persisted through 24 weeks of treatment.
Assuntos
Buprenorfina, Transtornos Relacionados ao Uso de Opioides, Humanos, Metadona/uso terapêutico, Analgésicos Opioides/efeitos adversos, Farmacogenética, Citocromo P-450 CYP3A, Antagonistas de Entorpecentes/efeitos adversos, Combinação Buprenorfina e Naloxona/uso terapêutico, Buprenorfina/uso terapêutico, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, Transtornos Relacionados ao Uso de Opioides/genética, Tratamento de Substituição de OpiáceosRESUMO
OBJECTIVES: Many emergency department (ED) patients with opioid use disorder are candidates for home buprenorphine/naloxone initiation with to-go packs. We studied patient opinions and acceptance of buprenorphine/naloxone to-go packs, and factors associated with their acceptance. METHODS: We identified patients at two urban EDs in British Columbia who met opioid use disorder criteria, were not presently on opioid agonist therapy and not in active withdrawal. We offered patients buprenorphine/naloxone to-go as standard of care and then administered a survey to record buprenorphine/naloxone to-go acceptance, the primary outcome. Survey domains included current substance use, prior experience with opioid agonist therapy, and buprenorphine/naloxone related opinions. Patient factors were examined for association with buprenorphine/naloxone to-go acceptance. RESULTS: Of the 89 patients enrolled, median age was 33 years, 27% were female, 67.4% had previously taken buprenorphine/naloxone, and 19.1% had never taken opioid agonist therapy. Overall, 78.7% believed that EDs should dispense buprenorphine/naloxone to-go packs. Thirty-eight (42.7%) patients accepted buprenorphine/naloxone to-go. Buprenorphine/naloxone to-go acceptance was associated with lack of prior opioid agonist therapy, less than 10 years of opioid use and no injection drug use. Reasons to accept included initiating treatment while in withdrawal; reasons to reject included prior unsatisfactory buprenorphine/naloxone experience and interest in other treatments. CONCLUSION: Although less than half of our study population accepted buprenorphine/naloxone to-go when offered, most thought this intervention was beneficial. In isolation, ED buprenorphine/naloxone to-go will not meet the needs of all patients with opioid use disorder. Clinicians and policy makers should consider buprenorphine/naloxone to-go as a low-barrier option for opioid use disorder treatment from the ED when integrated with robust addiction care services.
RéSUMé: OBJECTIFS: De nombreux patients des services d'urgence (SU) atteints d'un trouble lié à la consommation d'opioïdes sont des candidats à l'initiation à la buprénorphine/naloxone à domicile avec des trousses à emporter. Nous avons étudié les opinions des patients et l'acceptation des paquets de buprénorphine/naloxone à emporter, ainsi que les facteurs associés à leur acceptation. MéTHODES: Nous avons identifié des patients à deux urgences urbaines de la Colombie-Britannique qui répondaient aux critères relatifs aux troubles liés à l'utilisation d'opioïdes, qui ne suivaient pas actuellement un traitement aux agonistes des opioïdes et qui n'étaient pas en sevrage actif. Nous avons offert aux patients la buprénorphine/naloxone à emporter comme norme de soins, puis nous avons administré une enquête pour enregistrer l'acceptation de la buprénorphine/naloxone à emporter, le critère de jugement principal. Les domaines d'enquête comprenaient la consommation actuelle de substances, l'expérience antérieure avec le traitement aux agonistes opioïdes et les opinions liées à la buprénorphine/naloxone. Les facteurs du patient ont été examinés pour déterminer l'association avec l'acceptation de la buprénorphine/naloxone à emporter. RéSULTATS: Sur 89 patients inscrits, l'âge médian était de 33 ans, 27,0% étaient des femmes, 67,4% avaient déjà pris de la buprénorphine/naloxone et 19,1% n'avaient jamais pris de traitement aux agonistes opioïdes. Dans l'ensemble, 78,7% des répondants étaient d'avis que les SU devraient distribuer des paquets de buprénorphine/naloxone à emporter. Trente-huit (42,7%) patients ont accepté la buprénorphine/naloxone à emporter. L'acceptation de la buprénorphine/naloxone à emporter était associée à l'absence de traitement antérieur par agonistes opioïdes, à moins de 10 ans d'utilisation d'opioïdes et à l'absence de consommation de drogues injectables. Les raisons d'accepter comprenaient le fait de commencer un traitement pendant le sevrage; les raisons de rejeter comprenaient une expérience antérieure insatisfaisante de buprénorphine/naloxone et un intérêt pour d'autres traitements. CONCLUSION: Bien que moins de la moitié de notre population à l'étude ait accepté la buprénorphine/naloxone à emporter lorsqu'elle lui était offerte, la plupart ont pensé que cette intervention était bénéfique. Isolément, la buprénorphine/naloxone à emporter à l'urgence ne répondra pas aux besoins de tous les patients atteints de troubles liés à l'utilisation d'opioïdes. Les cliniciens et les décideurs devraient considérer la buprénorphine/naloxone à emporter comme une option à faible barrière pour le traitement des troubles liés à la consommation d'opioïdes par l'urgence lorsqu'elle est intégrée à de solides services de soins de la toxicomanie.
Assuntos
Antagonistas de Entorpecentes, Transtornos Relacionados ao Uso de Opioides, Humanos, Feminino, Adulto, Masculino, Antagonistas de Entorpecentes/uso terapêutico, Analgésicos Opioides/uso terapêutico, Combinação Buprenorfina e Naloxona/uso terapêutico, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, Transtornos Relacionados ao Uso de Opioides/epidemiologia, Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND AND OBJECTIVES: Buprenorphine/naloxone (BUP-NX) and methadone are used to treat opioid use disorder (OUD), yet there is insufficient evidence on the impact of doses on interventions' effectiveness and safety when treating OUD attributable to other opioids than heroin. METHODS: We explored associations between methadone and BUP-NX doses and treatment outcomes using data from OPTIMA, a 24-week, pragmatic, open-label, multicenter, pan-Canadian, randomized controlled, two-arm parallel trial with participants (N = 272) with OUD who primarily use opioids other than heroin. Participants were randomized to receive flexible take-home BUP-NX (n = 138) or standard supervised methadone treatment (n = 134). We examined associations between highest BUP-NX and methadone doses, and (1) percentage of opioid-positive urine drug screens (UDS); (2) retention in the assigned treatment; and (3) adverse events (AEs). RESULTS: The mean (SD) highest BUP-NX and methadone dose were 17.31 mg/day (8.59) and 67.70 mg/day (34.70). BUP-NX and methadone doses were not associated with opioid-positive UDS percentages or AEs. Methadone dose was associated with higher retention in treatment (odds ratio [OR]: 1.025; 95% confidence interval [CI]: 1.010; 1.041), while BUP-NX dose was not (OR: 1.055; 95% CI: 0.990; 1.124). Higher methadone doses (70-110 mg/day) offered higher odds of treatment retention. DISCUSSION AND CONCLUSION: Methadone dose was associated with higher retention, which may be related to its full µ-opioid receptor agonism. Future research should notably ascertain the effect of pace of titration on a wide range of outcomes. SCIENTIFIC SIGNIFICANCE: Our results extend previous findings of high doses of methadone increasing retention to be applied in our population using opioids other than heroin, including highly potent opioids.
Assuntos
Buprenorfina, Transtornos Relacionados ao Uso de Opioides, Humanos, Combinação Buprenorfina e Naloxona/uso terapêutico, Metadona/efeitos adversos, Analgésicos Opioides/efeitos adversos, Heroína, Tratamento de Substituição de Opiáceos/efeitos adversos, Tratamento de Substituição de Opiáceos/métodos, Canadá, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, Buprenorfina/efeitos adversos, Prescrições, Antagonistas de Entorpecentes/efeitos adversosRESUMO
OBJECTIVE: Extensive exposure to prescription-type opioids has resulted in major harm worldwide, calling for better-adapted approaches to opioid agonist therapy. The authors aimed to determine whether flexible take-home buprenorphine/naloxone is as effective as supervised methadone in reducing opioid use in prescription-type opioid consumers with opioid use disorder. METHODS: This seven-site, pan-Canadian, 24-week, pragmatic, open-label, noninferiority, two-arm parallel randomized controlled trial involved treatment-seeking adults with prescription-type opioid use disorder. Participants were randomized in a 1:1 ratio to treatment with sublingual buprenorphine/naloxone (target dosage, 8 mg/2 mg to 24 mg/6 mg per day; flexible take-home dosing) or oral methadone (≈60-120 mg/day; closely supervised). The primary outcome was the proportion of opioid-free urine drug screens over 24 weeks (noninferiority margin, 15%). All randomized participants were analyzed, excluding one who died shortly after randomization, for the primary analysis (modified intention-to-treat analysis). RESULTS: Of 272 participants recruited (mean age, 39 years [SD=11]; 34.2% female), 138 were randomized to buprenorphine/naloxone and 134 to methadone. The mean proportion of opioid-free urine drug screens was 24.0% (SD=34.4) in the buprenorphine/naloxone group and 18.5% (SD=30.5) in the methadone group, with a 5.6% adjusted mean difference (95% CI=-0.3, +∞). Participants in the buprenorphine/naloxone group had 0.47 times the odds (95% CI=0.24, 0.90) of being retained in the assigned treatment compared with those in the methadone group. Overall, 24 drug-related adverse events were reported (12 in the buprenorphine/naloxone group [N=8/138; 5.7%] and 12 in the methadone group [N=12/134; 9.0%]) and mostly included withdrawal, hypogonadism, and overdose. CONCLUSIONS: The buprenorphine/naloxone flexible model of care was safe and noninferior to methadone in reducing opioid use among people with prescription-type opioid use disorder. This flexibility could help expand access to opioid agonist therapy and reduce harms in the context of the opioid overdose crisis.
Assuntos
Buprenorfina, Overdose de Drogas, Transtornos Relacionados ao Uso de Opioides, Adulto, Analgésicos Opioides/uso terapêutico, Buprenorfina/uso terapêutico, Combinação Buprenorfina e Naloxona/uso terapêutico, Canadá, Feminino, Humanos, Masculino, Metadona/uso terapêutico, Antagonistas de Entorpecentes, Tratamento de Substituição de Opiáceos/métodos, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, PrescriçõesAssuntos
Alcoolismo/tratamento farmacológico, Depressores do Apetite/administração & dosagem, Dissuasores de Álcool/administração & dosagem, Dissuasores de Álcool/uso terapêutico, Alcoolismo/fisiopatologia, Depressores do Apetite/análise, Humanos, Naltrexona/administração & dosagem, Naltrexona/uso terapêutico, Apoio Social, Topiramato/administração & dosagem, Topiramato/uso terapêuticoRESUMO
BACKGROUND AND AIMS: To improve evidence-based addiction care in acute care settings, many hospitals across North America are developing an inpatient addiction medicine consultation service (AMCS). St Paul's Hospital in Vancouver, Canada houses a large interdisciplinary AMCS. This study aimed to: (1) describe the current model of clinical care and its evolution over time; (2) evaluate requests for an AMCS consultation over time; (3) highlight the established clinical training opportunities and educational curriculum and (4) provide some lessons learned. DESIGN, SETTING AND PARTICIPANTS: A retrospective observational analysis in an urban, academic hospital in Vancouver, Canada with a large interdisciplinary AMCS, studied from 2013 to 2018, among individuals who presented to hospital and had a substance use disorder. MEASUREMENTS: Data were collected using the hospital's electronic medical records. The primary outcome was number of AMCS consultations over time. FINDINGS: In 2014 the hospital's AMCS was restructured into an academic, interdisciplinary consultation service. A 228% increase in the number of consultations was observed between 2013 (1 year prior to restructuring) and 2018 (1373 versus 4507, respectively; P = 0.027). More than half of AMCS consultations originated from the emergency department, with this number increasing over time (55% in 2013 versus 74% in 2018). Referred patients were predominantly male (> 60% in all 5 years) between the ages of 45 and 65 years. Reasons for consultation remained consistent and included: opioids (33%), stimulants (30%), alcohol (23%) and cannabis use (8%). CONCLUSIONS: After St Paul's Hospital in Vancouver, Canada was restructured in 2014 to a large, interdisciplinary addiction medicine consultation service (AMCS), the AMCS saw a 228% increase in the number of consultation requests with more than half of requests originating from the emergency department. Approximately two-thirds of consultation requests were for opioid or stimulant use.
Assuntos
Medicina do Vício, Idoso, Canadá, Hospitais Urbanos, Humanos, Masculino, Pessoa de Meia-Idade, Encaminhamento e Consulta, Estudos RetrospectivosRESUMO
Background and Aims: Little is known about how the expansion of opioid agonist therapy (OAT) and emergence of fentanyl in the illicit drug supply in North America has influenced non-fatal opioid overdose (NFOD) risk. Therefore, we sought to identify patterns of substance use and addiction treatment engagement (i.e., OAT, other inpatient or outpatient treatment) prior to NFOD, as well as the trends and correlates of each pattern among people who use drugs (PWUD) in Vancouver, Canada. Methods: Data were derived from participants in three prospective cohorts of PWUD in Vancouver in 2009-2016. Observations from participants reporting opioid-related NFOD in the previous six months were included. A latent class analysis was used to identify classes based on substances used at the time of last NFOD and addiction treatment engagement in the month prior to the last NFOD. Multivariable generalized estimating equations estimated the correlates of each class membership. Results: In total, 889 observations from 570 participants were included. Four distinct classes were identified: (1) polysubstance use (PSU) and addiction treatment engagement; (2) PSU without treatment engagement; (3) exposure to unknown substances, mostly without treatment engagement; and (4) primary heroin users without treatment engagement. The class of exposure to unknown substances appeared in 2015 and became the dominant group (76.9%) in 2016. In multivariable analyses, the odds of membership in the class of primary heroin users decreased over time (adjusted odds ratio [AOR]: 0.74, 95% confidence interval [CI]: 0.68-0.81). Conclusions: Changing profiles of PWUD reporting opioid-related NFOD were seen over time. Notably, there was a sudden increase in reports of overdose following exposure to unknown substances since 2015, the majority of whom reported no recent addiction treatment engagement. Further study into patterns of substance use and strategies to improve addiction treatment engagement is needed to improve and focus overdose prevention efforts.
Assuntos
Overdose de Opiáceos/epidemiologia, Tratamento de Substituição de Opiáceos/tendências, Transtornos Relacionados ao Uso de Opioides/epidemiologia, Adulto, Colúmbia Britânica/epidemiologia, Feminino, Dependência de Heroína/epidemiologia, Dependência de Heroína/terapia, Humanos, Análise de Classes Latentes, Masculino, Pessoa de Meia-Idade, Transtornos Relacionados ao Uso de Opioides/terapia, Fatores de TempoRESUMO
INTRODUCTION: In the context of the opioid crisis in North America, the benefits of evidence-based opioid agonist treatments such as buprenorphine/naloxone have not been optimised due to low uptake. Numerous factors contribute to the underuse of buprenorphine, and theory-informed approaches to identify and address implementation barriers and facilitators are needed. This scoping review aims to characterise the barriers and facilitators at the patient, healthcare professional, organisation and system level according to the Theoretical Domains Framework (TDF), and identify gaps to inform practice and policy. METHODS AND ANALYSIS: We will conduct a scoping review using established methods and follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. We will identify English and French-language peer-reviewed literature by searching five electronic bibliographic databases (MEDLINE, Embase, PsychINFO, CINAHL, and SocINDEX), from inception and use Google, websites of key organisations, and two or more custom search engines to identify relevant grey literature. Eligible records will be quantitative or qualitative studies that examine barriers and facilitators to buprenorphine use at the patient, healthcare professional, organisation and system level, and involve participants with diagnosis of opioid use disorder or professionals involved in their care. Two reviewers will be involved in independently screening, reviewing and charting the data and calibration exercises will be conducted at each stage. We will conduct descriptive analysis for the charted data, and deductively code barriers and facilitators using the TDF. ETHICS AND DISSEMINATION: As a scoping review of the literature, this study does not require ethics approval. Our dissemination strategy will focus on developing tailored activities to meet the needs of diverse knowledge user audiences. Barriers and facilitators mapped to the TDF can be linked to evidence-based strategies for change to improve buprenorphine use and access, and enable practice to reduce opioid-related harms.
Assuntos
Buprenorfina/uso terapêutico, Tratamento de Substituição de Opiáceos, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, Padrões de Prática Médica/estatística & dados numéricos, Atenção Primária à Saúde/estatística & dados numéricos, Analgésicos Opioides/uso terapêutico, Humanos, Projetos de Pesquisa, Literatura de Revisão como AssuntoRESUMO
BACKGROUND: North America is in the midst of an opioid overdose epidemic. Although take-home naloxone and other measures have been an effective strategy to reduce overdoses, many events are unwitnessed and mortality remains high amongst those using drugs alone. While wearable devices that can detect and alert others of an overdose are being developed, willingness of people who use drugs to wear such a device has not been described. METHODS: Drug using persons enrolled in a community-recruited cohort in Vancouver, Canada, were asked whether or not they would be willing to wear a device against their skin that would alert others in the event of an overdose. Logistic regression was used to identify factors independently associated with willingness to wear such a device. RESULTS: Among the 1061 participants surveyed between December 2017 and May 2018, 576 (54.3%) were willing to wear an overdose detection device. Factors independently associated with willingness included ever having overdosed (adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI] 1.06-1.83), current methadone treatment (AOR = 1.86, 95% CI 1.45-2.40), female gender AOR = 1.41, 95% CI 1.09-1.84) and a history of chronic pain (AOR = 1.53, 95% CI 1.19-1.96). Whereas homelessness (AOR = 0.67, 95% CI 0.50-0.91) was negatively associated with willingness. CONCLUSIONS: A high level of willingness to wear an overdose detection device was observed in this setting and a range of factors associated with overdose were positively associated with willingness. Since some factors, such as homelessness may be a barrier, further research is needed to investigate explanations for unwillingness and to evaluate real world acceptability of a wearable overdose detection devices as this technology becomes available.
Assuntos
Overdose de Drogas/diagnóstico, Transtornos Relacionados ao Uso de Opioides/psicologia, Dispositivos Eletrônicos Vestíveis/psicologia, Adulto, Canadá, Dor Crônica/epidemiologia, Feminino, Humanos, Masculino, Pessoa de Meia-Idade, Transtornos Relacionados ao Uso de Opioides/epidemiologia, Fatores Sexuais, Fatores Socioeconômicos, Transtornos Relacionados ao Uso de Substâncias/epidemiologiaRESUMO
Importance: Although prescription opioid use disorder is associated with substantial harms, strategies to identify patients with pain among whom prescription opioids can be safely prescribed have not been systematically reviewed. Objective: To review the evidence examining factors associated with opioid addiction and screening tools for identifying adult patients at high vs low risk of developing symptoms of prescription opioid addiction when initiating prescription opioids for pain. Data Sources: MEDLINE and Embase (January 1946 to November 2018) were searched for articles investigating risks of prescription opioid addiction. Study Selection: Original studies that were included compared symptoms, signs, risk factors, and screening tools among patients who developed prescription opioid addiction and those who did not. Data Extraction and Synthesis: Two investigators independently assessed quality to exclude biased or unreliable study designs and extracted data from higher quality studies. The Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Accuracy Studies (PRISMA-DTA) reporting guideline was followed. Main Outcomes and Measures: Likelihood ratios (LRs) for risk factors and screening tools were calculated. Results: Of 1287 identified studies, 6 high-quality studies were included in the qualitative synthesis and 4 were included in the quantitative synthesis. The 4 high-quality studies included in the quantitative synthesis were all retrospective studies including a total of 2â¯888â¯346 patients with 4470 cases that met the authors' definitions of prescription opioid addiction. A history of opioid use disorder (LR range, 17-22) or other substance use disorder (LR range, 4.2-17), certain mental health diagnoses (eg, personality disorder: LR, 27; 95% CI, 18-41), and concomitant prescription of certain psychiatric medications (eg, atypical antipsychotics: LR, 17; 95% CI, 15-18) appeared useful for identifying patients at high risk of opioid addiction. Among individual findings, only the absence of a mood disorder (negative LR, 0.50; 95% CI, 0.45-0.52) was associated with a lower risk of opioid addiction. Despite their widespread use, most screening tools involving combinations of questions were based on low-quality studies or, when diagnostic performance was assessed among high-quality studies, demonstrated poor performance in helping to identify patients at high vs low risk. Conclusions and Relevance: While a history of substance use disorder, certain mental health diagnoses, and concomitant prescription of certain psychiatric medications appeared useful for identifying patients at higher risk, few quality studies were available and no symptoms, signs, or screening tools were particularly useful for identifying those at lower risk.
Assuntos
Analgésicos Opioides/uso terapêutico, Dor Crônica/tratamento farmacológico, Transtornos Relacionados ao Uso de Opioides/diagnóstico, Feminino, Humanos, Masculino, Transtornos do Humor/epidemiologia, Padrões de Prática Médica, Estudos Retrospectivos, Medição de Risco, Fatores de RiscoRESUMO
BACKGROUND: Gamma-hydroxybutyrate (GHB)-a GABA-B agonist-can lead to a use disorder, and a withdrawal syndrome similar to that of alcohol. At present, evidence is lacking for how to best manage GHB withdrawal, and often clinicians rely on alcohol withdrawal management approaches, using medications like benzodiazepines (BZD). However, BZD doses needed to control GHB withdrawal symptoms are typically much higher than those required for alcohol, posing significant safety risks. Novel approaches include the use of baclofen as an adjunct to BZD, allowing reductions in BZD requirements. While the use of baclofen as monotherapy may result in even greater risk reductions, research to support this approach is limited. CASE: We present a case of a 26-year-old female with severe GHB use disorder and history of severe withdrawal symptoms, whose withdrawal was successfully, managed using baclofen alone. CONCLUSION: In keeping with other case reports, baclofen appears to have potential to be used in the management of GHB withdrawal. Here, we presented a case of severe GHB withdrawal which was managed solely by baclofen. Clinical research is needed to evaluate baclofen's potential as a standalone treatment for GHB withdrawal.
Assuntos
Baclofeno/administração & dosagem, Agonistas dos Receptores de GABA-B/administração & dosagem, Oxibato de Sódio/efeitos adversos, Síndrome de Abstinência a Substâncias/tratamento farmacológico, Adulto, Feminino, Humanos, Resultado do TratamentoRESUMO
Background: Overdose deaths as a result of untreated opioid use disorder (OUD) pose a major public health concern across North America. Although slow-release oral morphine (SROM) is increasingly used as an alternative option for the treatment of OUD, research on its efficacy among individuals exposed to illicit fentanyl or those with previous unsuccessful attempts with other opioid agonist therapies (OATs) is limited and controversial. Case: We present a case of a 48-year-old male with severe OUD seeking treatment following a near-fatal fentanyl overdose. His previous treatment attempts with methadone and buprenorphine/naloxone-based OAT had been unsuccessful. As per local guidelines, he was started on SROM with subsequent cessation of opioid cravings and illicit drug use. Discussion: This case report describes a patient entering early remission for OUD when treated with SROM following unsuccessful past treatment attempts on first-line oral medications. Future studies should seek to evaluate SROM-based OAT as a potential second-line treatment alternative for OUD.
Assuntos
Alfentanil/intoxicação, Overdose de Drogas/tratamento farmacológico, Morfina/administração & dosagem, Abuso de Substâncias por Via Intravenosa/tratamento farmacológico, Administração Oral, Preparações de Ação Retardada, Humanos, Masculino, Pessoa de Meia-IdadeRESUMO
Background: Hospital-based clinical addiction medicine training can improve knowledge of clinical care for substance-using populations. However, application of structured, self-assessment tools to evaluate differences in knowledge gained by learners who participate in such training has not yet been addressed. Methods: Participants (n = 142) of an elective with the hospital-based Addiction Medicine Consult Team (AMCT) in Vancouver, Canada, responded to an online self-evaluation survey before and immediately after the structured elective. Areas covered included substance use screening, history taking, signs and symptoms examination, withdrawal treatment, relapse prevention, nicotine use disorders, opioid use disorders, safe prescribing, and the biology of substance use disorders. A purposefully selected sample of 18 trainees were invited to participate in qualitative interviews that elicited feedback on the rotation. Results: Of 168 invited trainees, 142 (84.5%) completed both pre- and post-rotation self-assessments between May 2015 and May 2017. Follow-up participants included medical students, residents, addiction medicine fellows, and family physicians in practice. Self-assessed knowledge of addiction medicine increased significantly post-rotation (mean difference in scores = 11.87 out of the maximum possible 63 points, standard deviation = 17.00; P < .0001). Medical students were found to have the most significant improvement in addiction knowledge (estimated mean difference = 4.43, 95% confidence interval = 0.76, 8.09; P = .018). Illustrative quotes describe the dynamics involved in the learning process among trainees. Conclusions: Completion of a hospital-based clinical elective was associated with improved knowledge of addiction medicine. Medical students appear to benefit more from the addiction elective with a hospital-based AMCT than other types of learners.
Assuntos
Medicina do Vício/educação, Currículo, Educação Médica/métodos, Educação em Enfermagem/métodos, Adulto, Colúmbia Britânica, Bolsas de Estudo, Hospitais, Humanos, Internato e Residência, Médicos de Família/educação, Pesquisa Qualitativa, Encaminhamento e Consulta, Serviço Social/educação, Estudantes de MedicinaRESUMO
Opioid overdoses (OD) cause substantial morbidity and mortality globally, and current emergency management is typically limited to supportive care, with variable emphasis on harm reduction and addictions treatment. Our urban setting has a high concentration of patients with presumed fentanyl OD, which places a burden on both pre-hospital and emergency department (ED) resources. From December 13, 2016, to March 1, 2017, we placed a modified trailer away from an ED but near the center of the expected area of high OD and accepted low-risk patients with presumed fentanyl OD. We provided OD treatment as well as on-site harm reduction, addictions care, and community resources. The primary outcome was the proportion of patients requiring transfer to an ED for clinical deterioration, while secondary outcomes were the proportion of patients initiated on opioid agonists and provided take-home naloxone kits. We treated 269 patients with opioid OD, transferred three (1.1%) to a local ED, started 43 (16.0%) on opioid agonists, and provided 220 (81.7%) with THN. Our program appears to be safe and may serve as a model for other settings dealing with a large numbers of opioid OD.
Assuntos
Analgésicos Opioides/intoxicação, Overdose de Drogas/tratamento farmacológico, Serviço Hospitalar de Emergência/organização & administração, Fentanila/intoxicação, Naloxona/uso terapêutico, Antagonistas de Entorpecentes/uso terapêutico, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, Adulto, Overdose de Drogas/mortalidade, Feminino, Humanos, Masculino, Pessoa de Meia-IdadeRESUMO
Importance: Although severe alcohol withdrawal syndrome (SAWS) is associated with substantial morbidity and mortality, most at-risk patients will not develop this syndrome. Predicting its occurrence is important because the mortality rate is high when untreated. Objective: To assess the accuracy and predictive value of symptoms and signs for identifying hospitalized patients at risk of SAWS, defined as delirium tremens, withdrawal seizure, or clinically diagnosed severe withdrawal. Data Sources: MEDLINE and EMBASE (1946-January 2018) were searched for articles investigating symptoms and signs predictive of SAWS in adults. Reference lists of retrieved articles were also searched. Study Selection: Original studies that were included compared symptoms, signs, and risk assessment tools among patients who developed SAWS and patients who did not. Data Extraction and Synthesis: Data were extracted and used to calculate likelihood ratios (LRs), sensitivity, and specificity. A meta-analysis was performed to calculate summary LR. Results: Of 530 identified studies, 14 high-quality studies that included 71â¯295 patients and 1355 relevant cases of SAWS (1051 cases), seizure (53 cases), or delirium tremens (251 cases) were analyzed. A history of delirium tremens (LR, 2.9 [95% CI 1.7-5.2]) and baseline systolic blood pressure 140 mm Hg or higher (LR, 1.7 [95% CI, 1.3-2.3) were associated with an increased likelihood of SAWS. No single symptom or sign was associated with exclusion of SAWS. Six high-quality studies evaluated combinations of clinical findings and were useful for identifying patients in acute care facilities at high risk of developing SAWS. Of these combinations, the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was most useful, with an LR of 174 (95% CI, 43-696; specificity, 0.93) when patients had 4 or more individual findings and an LR of 0.07 (95% CI, 0.02-0.26; sensitivity, 0.99) when there were 3 or fewer findings. Conclusions and Relevance: Assessment tools that use a combination of symptoms and signs are useful for identifying patients at risk of developing severe alcohol withdrawal syndrome. Most studies of these tools were not fully validated, limiting their generalizability.
Assuntos
Alcoolismo/complicações, Etanol/efeitos adversos, Medição de Risco/métodos, Síndrome de Abstinência a Substâncias/etiologia, Feminino, Humanos, Incidência, Funções Verossimilhança, Masculino, Fatores de Risco, Sensibilidade e Especificidade, Índice de Gravidade de Doença, Síndrome de Abstinência a Substâncias/epidemiologiaRESUMO
BACKGROUND: Rates of non-medical use of opioids, and opioid use disorders (OUD) have been rising throughout North America. Methadone and buprenorphine/naloxone are the recommended first-line treatment options for OUD in Canada. Most studies to date have been conducted among heroin users, in controlled settings, and using similar strict dosing schedules (i.e., daily witnessed ingestion) despite buprenorphine/naloxone's superior safety profile, which allows a more flexible take-home dosing schedule. This study was designed to assess the relative effectiveness of buprenorphine/naloxone- and methadone-based models of opioid agonist therapy (OAT) for the treatment of prescription opioid use disorder (POUD) in routine clinical care. METHODS: OPTIMA is a multicenter, open-label, pragmatic, randomized, two-arm, non-inferiority, 24-week study comparing the relative effectiveness of buprenorphine/naloxone (provided via flexible take-home doses) to methadone (provided via daily witnessed ingestion) models of OAT for the treatment of POUD. Approximately 276 non-pregnant adults meeting DSM-5 criteria for OUD, currently not in OAT, will be randomized across 7 Canadian sites. The primary outcome is reduction of non-medical opioid use, measured by bi-weekly urine drug screens during the 24-week study period. Secondary outcomes include treatment retention and satisfaction, safety, medication adherence, and patient engagement. DISCUSSION: The OPTIMA study is the first randomized clinical trial to compare the relative effectiveness of buprenorphine/naloxone (flexible take-home doses) versus methadone (daily witnessed ingestion) models of OAT for POUD in real-world clinical settings. This study will generate urgently needed evidence towards treatment options to guide the health system response to the ongoing opioid crisis. CLINICAL TRIAL REGISTRATION: NCT03033732.
Assuntos
Combinação Buprenorfina e Naloxona/administração & dosagem, Metadona/administração & dosagem, Transtornos Relacionados ao Uso de Opioides, Uso Excessivo de Medicamentos Prescritos/prevenção & controle, Adulto, Analgésicos Opioides/administração & dosagem, Técnicas de Observação do Comportamento, Canadá, Esquema de Medicação, Feminino, Humanos, Masculino, Antagonistas de Entorpecentes/administração & dosagem, Avaliação das Necessidades, Tratamento de Substituição de Opiáceos/métodos, Tratamento de Substituição de Opiáceos/psicologia, Transtornos Relacionados ao Uso de Opioides/diagnóstico, Transtornos Relacionados ao Uso de Opioides/psicologia, Transtornos Relacionados ao Uso de Opioides/terapia, Detecção do Abuso de Substâncias/métodosAssuntos
Analgésicos Opioides/uso terapêutico, Combinação Buprenorfina e Naloxona/uso terapêutico, Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico, Canadá, Overdose de Drogas/tratamento farmacológico, Humanos, Transtornos Relacionados ao Uso de Opioides/diagnóstico, Psicoterapia, Sociedades Médicas, Populações VulneráveisRESUMO
BACKGROUND AND AIM: Although methadone, an opioid agonist, has been an effective medication used to treat opioid use disorder for over 40years, recent studies have found that methadone was identified in more than a quarter of prescription opioid-related deaths among people who use illicit drugs in Vancouver, Canada. Thus, we sought to longitudinally examine the availability of diverted methadone among people who inject drugs (PWID). DESIGN AND METHODS: Data were collected from three prospective cohorts of PWID in Vancouver, Canada between December 2005 and May 2015. Multivariable generalized estimating equation logistic regression was used to identify temporal trends in the immediate availability of diverted methadone (defined as the ability to acquire illicit methadone in <10min). RESULTS: A total of 2092 participants, including 727 (34.8%) women, were included in the present study. In the multivariable analyses after adjusting for a range of potential confounders, later calendar year (adjusted odds ratio [AOR]=1.21 per year; 95% confidence interval [CI]: 1.19-1.23) was independently and positively associated with reporting immediate availability of diverted methadone. CONCLUSIONS: We observed a significant increase in the reported availability of diverted methadone among PWID over a ten-year follow-up period. Further research is needed to identify strategies to limit methadone diversion and assess the impact of alternative medications that are equally effective but safer, such as buprenorphine/naloxone.
